Questions and answers about the Affordable Care Act’s impact

A: Polls show many Americans remain mystified by the Patient Protection and Affordable Care Act, or “Obamacare” as it is commonly known. But there’s an obvious starting point: Do you have health care coverage?

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Health and Human Services Secretary Kathleen Sebelius has played a key role in refining provisions of the Affordable Care Act, including oversight of states’ insurance marketplaces. The Associated Press

The clock is running out for Senate Minority Leader Mitch McConnell and other Republicans who are trying to delay the implementation of “Obamacare.” The Associated Press

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If your employer provides health insurance for you, it’s likely you don’t have to do anything on Oct. 1, when enrollment begins. Enrollment continues through March 31. Coverage will start on Jan. 1.

For others — those without insurance — it’s more complicated.

The law requires virtually all U.S. citizens and legal residents to have coverage or pay a penalty. That will happen either through an expanded government Medicaid program, which would cover costs for lower-income people, or by requiring people without coverage to buy it. Financial help will be available for those who qualify, based on income.

In Maine, expansion of Medicaid was rejected by Gov. Paul LePage. He vetoed an expansion of MaineCare — as Medicaid is called in Maine — earlier this year, effectively denying coverage to more than 70,000 uninsured Maine residents. The issue is likely to resurface when the Legislature reconvenes in January.

There are just a few exceptions to the requirement for coverage under the Affordable Care Act, including prison inmates, people who entered the country illegally, those facing financial hardship and religious objectors.

WHEN DO I HAVE TO DECIDE WHETHER TO BUY HEALTH INSURANCE AND WHAT HAPPENS IF I DON’T?

A: Beginning in 2014, virtually all Americans will be required to have health insurance or pay an annual penalty to the government. For an individual, the fine begins at a minimum of $95 in 2014, stepping up annually to a minimum of $695 by 2016. The fine for uninsured children in 2014 is $47.50 for each child, although the maximum a family would have to pay in penalties next year is $285. Those fees climb each year.

Federal researchers predict that about 6 million people could be hit with fines by 2016.

Those who owe penalties would see their tax refunds docked. Not everyone who fails to buy insurance will be forced to pay up — those exempted from the requirement to have insurance, such as prison inmates, would not be penalized, for example. That also would be the case with people who earn so little that they are not required to file a tax return.

According to the government, the Internal Revenue Service plans to hold back the amount of the penalty fee from future tax refunds, but there are no liens or criminal penalties for failing to pay.

WHAT ARE THE HEALTH INSURANCE MARKETPLACES, PREVIOUSLY KNOWN AS EXCHANGES, AND HOW DO THEY WORK?

A: The marketplace is the online forum through which individuals and small businesses will buy private health insurance. Think of them as one-stop-shopping destinations similar to Amazon.com that are supposed to give consumers a quick way to compare insurance policies. Consumers are expected to be able to see all their options in the exchanges and choose their health plans based on price, deductibles and co-payments.

Maine residents who buy mid-level plans in the health insurance marketplace created under the Affordable Care Act will pay more than the national average but less than what individuals have paid in the past. Health care coverage is more costly in Maine because it is a rural state with an older population and lacks insurance competition, experts say.

Many participants will qualify for federal subsidies in the form of tax credits to help ease the cost. The amount is based on income and is available to individuals making up to $45,960, or $94,200 for a family of four.

The Maine Bureau of Insurance expects 5 percent to 8 percent of state residents, or 65,000 to 104,000 people, to purchase insurance in the marketplace. The federal government aims to sign up 7 million people in the U.S. in the first year.

Helpers, or navigators, will be available in Maine and elsewhere to help people figure out what policy may be right for them. To find a navigator in Maine, consumers can call 2-1-1. The website www.enroll207.com will provide state-specific information about health plan options and offers a ZIP code locator that will help people find navigators and “certified assisters” in their communities. The site also will provide a link to www.Healthcare.gov, the federal Health Insurance Marketplace website, to purchase coverage.

The federal government has set up call centers to help people with open enrollment. Call 1-800-318-2596 (TTY: 1-855-889-4325). The number is staffed 24 hours a day. Information is available in more than 150 languages.

HOW WILL ACTUAL HEALTH CARE COVERAGE AND SERVICES BE DIFFERENT UNDER OBAMACARE?

A: Coverage in the marketplace will be more comprehensive than what is typically available to individuals in the current health insurance market, which is dominated by bare-bones plans. The plans will have to cover a standard set of benefits, but will vary in price based on deductibles and co-payments. All plans in the exchange, and most outside it, will have to cover care such as prescriptions, emergency room treatment, and maternal and newborn care.

Under the law, insurers can’t turn away people or charge them more because of health problems or chronic illnesses. Insurers also are banned from setting different rates based on gender. Middle-aged and older adults can’t be charged more than three times what young people pay, but insurers can impose penalties on smokers.

Most health insurance plans have to cover certain preventive services. Those include routine vaccinations, vision and hearing tests for children, and screenings for diabetes, high cholesterol, colon cancer and high blood pressure.

I CURRENTLY HAVE INSURANCE THROUGH MY EMPLOYER. WILL ANYTHING CHANGE?

A: Maybe. For many people who have health insurance through their employer, the Kaiser Family Foundation says not a lot is expected to happen right away.

Some workers may receive a financial break from the new cap on out-of-pocket expenses and free preventive care. But some larger companies, those with 50 or more employees, already are looking for ways to cut costs and avoid getting hit with a new tax set to take effect in 2018 on so-called “Cadillac” insurance plans. Those are defined as plans valued at $10,200 or more for individual coverage and $27,500 for family policies.

Some companies have taken steps to save money on health insurance coverage. United Parcel Service, for example, informed its white collar employees that it will no longer cover spouses if they can get coverage through their own employers. Delta Air Lines, meanwhile, recently predicted its workers may have to help shoulder the cost of various new mandates under the Affordable Care Act, such as coverage for employees’ children until they are 26 years old, and coverage for workers who previously opted out but will now be required to have health insurance.

IF I GET HEALTH CARE COVERAGE THROUGH MY EMPLOYER, CAN I STILL BUY COVERAGE IN THE MARKETPLACE?

A: If your employer’s coverage is not considered “affordable,” or if your employer’s plan pays less than 60 percent of the cost of covered benefits, you can shop for other coverage and be eligible for a subsidy. Under the Affordable Care Act, “affordable” is defined as 9.5 percent of an employee’s household income.

The 9.5 percent test, however, only applies to what it would cost the employee to get coverage only for himself or herself. It does not apply to the cost of coverage that person may want to buy as part of a family plan. If coverage for the employee is less than 9.5 percent of household income, then the employee and family members are ineligible for subsidies.

THE GOVERNMENT HAS DELAYED THE LARGE-BUSINESS MANDATE FOR A YEAR, BUT WHAT WILL THE LAW MEAN FOR OWNERS OF SMALLER BUSINESSES?

A: Under the Affordable Care Act, a small business is defined as having anywhere from two to 50 employees. Those firms are not required to provide their workers with health insurance. In Maine, most companies are considered small or micro-businesses. In fact, 80 percent of Maine businesses have fewer than 10 employees.

Larger businesses with employment levels close to the 50-employee threshold have until 2015 to calculate whether it’s worth reducing their workforce or cutting workers’ hours to avoid a series of escalating penalties that kick in if just one of their employees ends up receiving government-subsidized health care.

WILL I BE FORCED TO CHANGE DOCTORS OR HEALTH PLANS EVEN IF I DON’T WANT TO, AND WILL MY CHOICES FOR BOTH BE LIMITED?

A: It depends. You can maintain your current providers if you have job-based insurance and can choose any available primary care provider in your insurance plan’s network. However, the influx of patients who will be newly insured under the Affordable Care Act could overwhelm the health care system in some areas. That could mean you will see a physician assistant or nurse practitioner, rather than a physician.

In general, the Obama administration says the law offers new rights and protections whether you have coverage or need it, but there are some exceptions. The new rights do not apply to health plans created or bought before March 23, 2010.

In Maine, there are two companies offering products in the marketplace — Anthem Blue Cross and Blue Shield and Maine Community Health Options. Anthem has proposed a network that includes only 32 of the 38 acute care hospitals in Maine. As a result, some residents in central and western Maine may need to change doctors if they buy an Anthem plan in the marketplace. If consumers want to keep their doctor, they can buy a plan from Maine Community Health Options or from a provider that is not in the marketplace. Outside of the marketplace, Mega Life and Harvard Pilgrim will also offer individual health insurance options.

Although critics have said the Anthem-MaineHealth pact goes against Obama’s pledge that consumers would not have to change doctors, the emergence of so-called narrow networks that exclude certain hospitals or providers is a trend emerging in other states as well.

IF I CURRENTLY BUY MY OWN INSURANCE, CAN I KEEP IT OR DO I HAVE TO CHANGE?

A: If you have individual insurance — a plan you bought yourself rather than what you get through an employer — you should be able to change to a new plan if you choose. Many popular plans in Maine, such as high-deductible plans that offer only catastrophic coverage, are not allowed under Obamacare, in part, because they do not provide broad coverage for a variety of health issues.

Anthem has requested permission from the Maine Bureau of Insurance to transfer some existing customers to new plans. That transfer would affect only 9,000 people in the state, Anthem said. Anthem customers who bought their plans before March 23, 2010, would be allowed to keep their coverage.

It will be illegal for insurance companies to cancel your coverage if you make simple mistakes on forms, but you still can be canceled for intentionally making false claims. If you have COBRA continuation health coverage, you can maintain it or decide to buy a new insurance plan. If you select a plan by Dec. 15, you can have coverage starting Jan. 1.

I KEEP HEARING ABOUT BRONZE, SILVER, GOLD AND PLATINUM. WHAT DOES THAT MEAN?

A: Bronze, silver, gold and platinum refer to the types of insurance policies available to businesses and individuals under the exchanges created by the health care law. The categories reflect how much premiums will cost each month and the amount you will pay for such things as hospital visits and prescription medications. The percentage covered by the plan increases from bronze to platinum.

The lowest-cost plan is bronze, in which the insurance company covers 60 percent of the expenses and the individual will pay 40 percent. The highest-cost tier is platinum, in which the insurer covers 90 percent of the expenses and the individual pays 10 percent.

The annual out-of-pocket costs for co-payments and deductibles top out at $6,350 for individuals and $12,700 for families.

IS “OBAMACARE” AVAILABLE FOR IMMIGRANTS?

A: It depends on whether they are in the country legally. Legal immigrants will be required to buy health insurance or pay a tax penalty if they don’t. They can buy insurance through the marketplace and are eligible for the subsidies.

Immigrants who are in the country illegally will not be eligible to buy insurance through a marketplace. They also are ineligible for Medicaid, although they remain eligible for emergency care under the law. Young immigrants who have been granted “deferred action” status by the Obama administration to avoid deportation by obtaining temporary work permits also will not be eligible for the new marketplace or Medicaid.

– The Associated Press and Staff Writer Jessica Hall contributed to this story.

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